Todd59 has described an expression of countenance which he designates as the facies hysterica. The characteristics of this expression are a remarkable depth and prominent fulness, with more or less thickness, of the upper lip, and a peculiar drooping of the upper eyelids. It would be absurd to assert that all hysterical patients presented this cast of countenance, but an appearance which approaches closely to this description is presented in a fair percentage of cases. It has seemed to me that male hysterics were more likely to have this peculiar facies than hysterical females.
59 Reynolds's System of Medicine, vol. ii. p. 656.
The psychical peculiarities or mental disorders of hysteria form a large and important part of its phenomena. We have to deal not only with peculiar and diverse psychical manifestations, but to one form of mental disorder it is clinically convenient and correct to apply the designation hysterical insanity.
In the mildest cases of ordinary hysteria conditions of mental irritability and mobility are sometimes the only striking features. “Patients,” says Jolly,60 “are timid, easily overcome by any unexpected occurrence, sentimental, and sensitive. Every trifle annoys and upsets them; and there is this peculiarity—that a more recent stimulus may often effect a diversion in an exactly opposite direction.”
60 Op. cit.
As bearing upon the question of the mental state in hysteria, the confessions obtained by Mitchell from several patients are of great interest. One patient, who had learned to notice and dwell upon any little symptom, vomited daily and aroused much sympathy. She took little or no food. Spasms came on, and she confessed that every new symptom caused new anxiety, and that somehow she rather liked it all. She gradually lost all her symptoms except vomiting, and overcame this by desperate efforts. Another patient confessed to having played a game upon her doctor for a long time by pretending she took no food. She would get out of bed at night, but remain there all day; she filled up a vessel with water to make others believe she passed large quantities of urine, etc. Another patient, a girl of nineteen, who came on a litter from a Western State, after a time regained her feet. In her confession she stated that what she lacked was courage. She believed that she would have overcome her difficulties if any one had told her that nothing was the matter. “In looking back over the year with the light of the present,” she says, “I can only say that I believe that there was really nothing the matter with me; only it seemed to me as if there was, and because of these sensations I carried on a sort of starvation process physical and mental.”
The older and some of the more recent classifications of insanity recognize hysterical insanity as a distinct form of mental disease. Morel and Skae, however, in their etiological classifications, and Hammond, Spitzka, Mann, and Clouston in their recently-published works, give it a “local habitation and a name.” Krafft-Ebing not only recognizes hysterical insanity as a distinct form of mental disease, but, after the German fashion, subdivides it quite minutely, as follows: First, transitory forms: a. with fright; b. hystero-epileptic deliria; c. ecstatic visionary forms; d. moria-like conditions. Second, chronic forms: a. hystero-melancholia; b. hystero-mania; c. degenerative states with hysterical basis.
Spitzka61 speaks of chronic hysterical insanity as an intensification of the hysterical character, to which “a silly mendacity is frequently added, and develops pari passu with advancing deterioration.” At the State Hospital for the Insane at Norristown and at the department for the insane of the Philadelphia Hospital cases of chronic hysterical insanity have come under my observation. Hammond under hysterical mania includes several different and somewhat distinct mental disorders.
61 Insanity, its Classification, Diagnosis, and Treatment, by E. C. Spitzka, M.D., New York, 1883.
With regard to the occurrence of hysterical manifestations amongst patients suffering from some well-recognized non-hysterical forms of insanity, a tour through any large asylum will afford abundant evidence. Cases of tremor closely simulating cerebro-spinal sclerosis have been observed frequently among the insane. Paralysis, contracture, hysterical joints, hysterical neuralgias, convulsions, and cataleptoid phenomena are among other hysterical manifestations which have fallen under personal observation among the insane of various classes.